RN – GRIEVANCE & APPEALS / UTILIZATION REVIEW

New York $50-55/HR
Monday–Friday | 9:00 AM–5:00 PM Full-Time | Long-Term Temporary Opportunity.




MUST HAVE STRONG OUTPATIENT UTILIZATION REVIEW EXPERIENCE! REQUIREMENTS Active New York State RN License – REQUIRED Strong OUTPATIENT Utilization Review / Clinical Review experience – REQUIRED Prior Authorization and Medical Necessity Review experience Grievance amp; Appeals experience strongly preferred Experience reviewing clinical documentation and applying medical necessity criteria Managed Care / Health Plan experience preferred Medicare, Medicaid and/or Medicare Advantage experience highly desirable Ability to work within strict regulatory and departmental turnaround times

RESPONSIBILITIES• Review and resolve grievances, appeals and external reviews involving medical necessity, quality of care, services, and benefits.• Conduct comprehensive clinical and outpatient utilization reviews, evaluating medical documentation and applying established medical criteria and regulatory requirements.• Review requests for prior authorization of healthcare services and prepare written responses consistent with regulatory requirements.• Investigate routine and complex appeals, identify key clinical issues, and coordinate with members, providers, Medical Management, Claims, Medical Directors and other departments.• Review covered and coordinated services to ensure appropriate appeal resolution and compliance with plan benefits and medical necessity criteria.• Prepare clinical cases and supporting documentation for physician/Medical Director review when necessary.• Coordinate external case reviews, including documentation associated with New York State Fair Hearings, CMS, Independent Review Entities and Quality Improvement Organizations.• Maintain detailed documentation of case activity, clinical rationale, determinations and appeal outcomes.• Develop correspondence communicating grievance and appeal decisions to members and/or providers.• Maintain compliance with all required state and federal regulatory guidelines and turnaround times.

IMPORTANT: Candidates must have strong, hands-on OUTPATIENT UTILIZATION REVIEW experience

. Candidates whose utilization review background is primarily inpatient may not meet the requirements for this opportunity.

Pay: $60/hour
Monday–Friday | 9:00 AM–5:00 PM
Long-Term Temporary Assignment
TO APPLY: Send your resume directly to

gzivali@phaxis.com

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